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City of Miami Beach Office of the City Clerk r:o~ N~' ~~,I~,~ _ Jc
1700 Convention Center Drive, Miami Beach, FL 33139 ~~ f~7
LOBBYIST REGISTRATION FORM
Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage the passage, defeat or modification of
any ordinance, resolution, action or decision of any commissioner; any action, decision, recommendation of the City Manager or any city board or
committee; or any action, decision or recommendation of any city personnel during the time period of the entire decision-making process on such
action, decision or recommendation that foreseeably will be heard or reviewed by the city commission, or a city board or committee. The term
specifically includes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please
refer to Ordinance 2004-3435. ~ j I
~f V PC~ r~ ~F' ~^ ~ L~
NAME OF LOBBYIST: (Last) ~ (First) (M~I)
~ ,j C ZI'-Z c;;~G~ ~ I _S - ~ ~ ~ ~d ~~r c~-rh r ~9' _ 3 ~ ~ 3 ~-
BUSINESS NAME AND ADDRESS (Number a ° Street) (City) (State) (Zip Code)
TELEPHONE NUMBER:
I. LOBBYIST RETAINED BY:
R / ~
NAME OF PRINCIP /CLIEN
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BUSINESS NAME AND ADDRE`~~
TELEPHONE NUMBER
FAX NUMBER:
~1 ~>~
and Street) fl (City)
~2 ~ - S ~, L
1X NUMBER: (Optional)
EMAIL:
EM
(Zip
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Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
u.SPECIFIC LOBBY 1S'SUE:
Issue to be lobbied (Describe in detail):
ul. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: (Pursuant to city code section z-48z(g>
include a statement of the extent of any business, financial, familial, professional or other relationship, giving raise to an
appearance of an impropriety, with any City personnel sought to be lobbied; further, pursuant to City Code Section 2-
482(a)(4) include a statement of any contractual relationship (paid or unpaid) from 12 months preceding the
commencement of service of City personnel to be lobbied.)
A Full Name of Individual Titfe B) An Financial, Familial or Professional Relationship
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IV. DISCLOSURE OF.TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
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On Procurement Issues": ~ '
^ Yes L~'IVo• Are you lobbvina on a present or pendina bid for goods equipment or services or on a r,
present or pending award for goods eauipment or service? y'`~
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
^ Yes ^~ Are you lobbvina on a pendina application for a Development Agreement with the City or
application for change of zoning map designation or chance to the Citv's Future Land Use
Map?
3) Pursuant to Miami Beach City Code 2-484 (h) Any person (except those exempt from the definition of
"lobbyist" as set forth in Section 2-481 above) who only appears as a representative of anot-for-profit
corporation or entity without special compensation or reimbursement for the appearance, whether direct, or
indirect, to express support of or opposition to any item, shall register with the clerk as required by this
section but, shall not be required to pay any registration fees.
_i6l Yes ^ No: Are you representing anot-for-profit corporation or entity without special compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 1sT OF EACH YEAR. EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH LISTING LOBBYING EXPENDITURES AS WELL AS COMPENSATION RECEIVED
~ ~ ,~,
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Loffipyists .~. .^
A) LOBBYIST DISCLOSURE: (Required)
/. ~ .
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): 1 D ~ C/~ ~ `.-Y~
(Required). ~ ~'•~ ~~
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The following information must be answered: `{ ~j' ~ ~.
Signature of Lobbyist:
Signature of Principal/Client: ~,
VI. LOBBYIST IDENTIFICA
PRINCIPAL IDENTIFICATION:
^ Produced ID
Form of Identification
ersonally known (Lobbyist)
Form of Identification
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to and subscribed before me
This Z `_day of SE^t~~T ,2698 2009
W~
Signature of Public Notary -State of Florida
Notarization of Lobbvist's signature
0 Produced ID
Personally known (Principal)
2o.~"av v~~c SANDY R. YYERINEIM
* * MY CAMMISSION N DD 637829
~, ~ EXPIRES: February 17, 2011
'~~ 13a,dearnN
State of Florida, County of Miami-D'~dQF~~` 8udgetNoierySerryicces
Sworn and subscribed before me
This Zi day of SST ,•'696- p9
Signature of Public Notary -State of Florida
Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: ]Yes [ ] No Amount Paid S /~- MCR # - Date Paid ~ - ~~
Lobbyist Registration Form received and verified by: _ --fr ., i- i Vii-
F:\CLER\L46BYIST\Labbvist Registration Farm 32708.doc~ _ ~'y,~C.-J Revised 03/27/2008
I do solemnly swear that all of the foregoing facts are true and correct and that I have read or am familiar with the
provisions contained in Section 2-482 of the Miami Beath City Code and all reporting requirements.
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov `~`~`; ~ ~`~'
CITY CLERK Office CityClerk@miamibeachfl.gov `~j' ~,
Tel: 305.673.741 1 ,Fax: 305.673.7254 ~~/'~ ~r
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LOBBYIST NAME: ~` II~~P.l~ ~ ~ ~~p~n~-~
I understand that no later than October 1st of each year, I must file the following
forms, pursuant fin Section 2-485 of the Miami Beach City Code, with the City Clerk's
Office for all active lobbying issues.
1) Lobbyist Expenditure Form
2) Disclosure Form
Failure to file these forms on a timely basis will result in my name being transmitted to the
Miami-Dade County Commission on Ethics and for code violation evaluation.
In addition, once an issue I have registered to lobby on has been resolved, I am required
to immediately notify the City Clerk's Office of lobbyist withdrawal in writing.
~ ~
Signature: ~=%'~~ ~ Date:
F:1Cl.ERILOBi3YISTlI_abbyist Registratian Farm 32708.doc